Mortality of Untreated Prostate Cancer

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ralfinaz
Veteran Member


Date Joined Jan 2011
Total Posts : 713
   Posted 10/8/2011 1:14 PM (GMT -6)   
Review of the medical literature —Mortality of Untreated Prostate Cancer.
Prostate cancer mortality before the PSA era. Why is the USPSTF ignoring this data? Should men ignore this data?

Contrary of what we currently hear, without early detection by PSA testing, prostate cancer is diagnosed at advanced stages that increase the risk of dying of the disease. This is the current situation on countries in which the use of PSA is very low. In countries in which PSA use is high, PCa mortality has been reduced. In such countries, those opposed to the use of PSA point to excessive over treatment. No question that over treatment exists and should be avoided. One way of doing this is applying active surveillance more often in cases of low-grade cancers as defined by the various current protocols and learn from that experience.

The amount of over treatment is in question. Computer models report a range of over diagnosis and over treatment of 25% to 85% depending on definition. In the Tyrol, Austria study where every patient diagnosed was treated, only 8.7% were over treated. This is actual data from an ongoing study and...not computer generated estimate. Before the introduction of the PSA test 75% of patients were diagnosed with symptoms of advanced disease and proportionally more men died of the disease.

What follows are selections from various sources related to the mortality of untreated prostate cancer:

1. Prostate cancer mortality was 80% in men younger than 60 years, 63% in men 60-69 years old, 53% in men 70-79 years old and 49% in men older than 80 years.
Source.
Damber JE, Grönberg H .Mortality due to prostatic carcinoma in northern Sweden. : Urologe A. 1996 Nov;35(6):443-5

2. Survival rates were adjusted for expected mortality in the general population and were expressed as relative survival (RS). RS for the total cohort after 5, 10 and 20 years was 51, 34 and 17% respectively, with an annual excess death rate of about 8% which persisted also after long-term observation. RS was similar in age groups between 45 and 74 years, whereas among patients older than 74 years at diagnosis approximately 10% lower RS appeared early and was persistent. RS improved for patients diagnosed at consecutive 5-year periods. Thus, the high mortality rate in old age groups and the low long-term RS contradicted the concept that biologically inactive tumours constitute a significant proportion of prostatic cancers diagnosed in clinical practice.
Source:
Norlén BJ. Survival and mortality in prostatic cancer. A study based on the Swedish Cancer Register. Acta Oncol. 1991;30(2):141-4.

3. RESULTS: Overall, 62% of patients with a known diagnosis of PC died of the
disease when all patients were followed from diagnosis until death (up to 25 years). Of patients in stage M0 at diagnosis, 50% died of PC. However, in patients who survived for more than 10 years the mortality reached 63%
Source:
Aus G .Prostate cancer. Mortality and morbidity after non-curative treatment with
aspects on diagnosis and treatment.
Scand J Urol Nephrol Suppl. 1994;167:1-41.

4. The results indicate that cancer specific mortality in patients with localized prostate cancer increases steadily over time and is approximately 50%. Localized prostate cancer is a slow-growing but progressive neoplastic disease. When diagnosed in a man with a longer life expectancy it should be handled as such.
Source:
Hugosson J, Aus G. Natural course of localized prostate cancer. a personal view with a review of published papers. Anticancer Res. 1997 May-Jun;17(3A):1441-8.

5. RESULTS: The study population was composed of 6514 patients diagnosed with prostate cancer during 1971 to 1987 in northern Sweden.
about 85% of these patients died during the 7 to 23 years of follow-up, and the
prostate cancer-specific mortality was estimated to be 55%. Age at diagnosis was
found to be a strong predictor of prostate cancer death. Patients diagnosed before the age of 60 had an 80% risk of dying of prostate cancer, whereas those over 80 years of age at diagnosis had less than a 50% risk of prostate cancer-related death.
Source:
Grönberg H, Damber L, Jonson H, Damber JE. Prostate cancer mortality in northern Sweden, with special reference to tumor grade and patient age.Urology. 1997 Mar;49(3):374-8.

6. The long-term outcome in patients with prostate cancer treated with palliative
intent was examined in two populations from Göteborg, Sweden. The results showed a prostate-cancer-related mortality of 62%. The cumulative mortality increased over time, indicating that prostate cancer may be a slow-growing tumour, but that patients were at considerable risk for disease progression and eventual death. Dying from prostate cancer was associated with a long hospital stay and frequent demands for palliative treatments such as TURP, radiation and procedures due to upper-urinary-tract obstruction. In a subpopulation of patients who survived for more than 10 years, the cancer-related mortality was surprisingly high, 62% after noncurative treatment. Even if the patients were diagnosed before the PSA era, the above findings should be taken into account when advising patients with prostate cancer about therapy if they have a long life expectancy.
Source:
Aus G, Hugosson J. [Non-curative treatment of prostate carcinoma. Outcome in
Göteborg]. Urologe A. 1996 Nov;35(6):449-53.

7. RESULTS: The total number of 719 new cases of prostate cancer were diagnosed without any screening programs. Forty-five percent of patients were diagnosed incidentally, and 31% of all patients had organ-confined disease (T1a-T2, Nx, M0). The disease specific survival rates at 1, 5, and 10 years were 80%, 38%, and 17%, respectively, and 62% of the patients died primarily of prostate carcinoma. A multivariate analysis demonstrated a statistically significant relationship between disease specific death and T classification, tumor differentiation, and erythrocyte sedimentation rate at diagnosis.
CONCLUSIONS: Prostate carcinoma patients have a poor survival and the majority of the patients diagnosed suffer and die from their disease rather than with it. Nevertheless, approximately one-third of patients neither suffer nor die from their disease. Therefore, the development of prognostic markers to improve the identification of patients who will benefit from early aggressive treatment is important.
Source:
Borre M, Nerstrøm B, Overgaard J. The natural history of prostate carcinoma based on a Danish population treated with no intent to cure .Cancer. 1997 Sep 1;80(5):917-28.

8. Computerized linkage between the Danish Cancer Registry and the Central Personal Registry was established. A total of 1459 men aged 55-74 years with newly diagnosed clinically localized prostate cancer in the period 1983-1987 were identified. Routine treatment in this period was observation and endocrine therapy in case of progression. Survival analysis demonstrated a significant excess mortality and a substantial loss of life expectancy.
Source:
Brasso K, Friis S, Juel K, Jørgensen T, Iversen P. [Localized prostatic cancer. Survival and loss of life expectancy].Ugeskr Laeger. 1998 Jul 27;160(31):4517-20.

9. Prostate cancer mortality in Norway is the highest among the Nordic countries and among the highest in the world. Five-year relative survival for all cases combined is 60%. Approximately 55-60% of the patients die from the disease.
Source:
Harvei S. [Epidemiology of prostatic cancer]. Tidsskr Nor Laegeforen. 1999 Oct
10;119(24):3589-94.

10. CONCLUSIONS: The disease-specific mortality was comparatively high, but it took 15 years to reach a disease-specific mortality rate of 56%. These data form a truly population-based baseline on how prostate carcinoma will affect a population when screening is not applied and can be used for comparison with other health care strategies.
Source:
Aus G, Robinson D, Rosell J, Sandblom G, Varenhorst E; South-East Region Prostate Cancer Group. Survival in prostate carcinoma--outcomes from a prospective, population-based cohort of 8887 men with up to 15 years of follow-up: results from three countries in the population-based National Prostate Cancer Registry of Sweden. Cancer. 2005 Mar 1;103(5):943-51.

11. Most cancers had an indolent course during the first 10 to 15 years. However,
further follow-up from 15 (when 49 patients were still alive) to 20 years revealed a substantial decrease in cumulative progression-free survival (from 45.0% to 36.0%), survival without metastases (from 76.9% to 51.2%), and prostate cancer-specific survival (from 78.7% to 54.4%). The prostate cancer mortality rate increased from 15 per 1000 person-years (95% confidence interval, 10-21) during the first 15 years to 44 per 1000 person-years (95% confidence interval, 22-88) beyond 15 years of follow-up (P =.01).
CONCLUSION: Although most prostate cancers diagnosed at an early stage have an indolent course, local tumor progression and aggressive metastatic disease may develop in the long term. These findings would support early radical treatment, notably among patients with an estimated life expectancy exceeding 15 years.
Source:
Johansson JE, Andrén O, Andersson SO, Dickman PW, Holmberg L, Magnuson A,
Adami HO. Natural history of early, localized prostate cancer. JAMA. 2004 Jun 9;291(22):271

Bottom line: The USPSTF’s recommendation as it stands will cause a reduction in
PSA testing. This reduction will increase the number of men diagnosed with
advanced disease and increase the number of PCa deaths. As PCa survivors will we allow that to happen? When the same panel tried the this strategy with breast cancer screening, women raised their concerns and the USPSTF backed off. We need to do the same. I would not be here today if not for the PSA test. It gave me the information needed to decide on treatment that ultimately prolonged my life. I am only a point in the PSA curve reducing prostate cancer deaths and that is motivation enough for me to be proactive on this issue.

RalphV
Phoenix, Arizona
DISCLAIMER: I am a prostate cancer survivor since 1992. The views or opinions expressed here are my own and are not endorsed nor supported by any agency or institution. Recommendations SHOULD NOT be construed as professional advice.
DX at age 58. RP; Orchiectomy; GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall; Stage T4; Last PSA July, 0'11: <0.1ng/ml

Dreamerboy
Regular Member


Date Joined Jul 2011
Total Posts : 383
   Posted 10/8/2011 1:46 PM (GMT -6)   
Thanks for posting this.
PSA: 7.4
Biopsy: July 4, 2011 @ age 52 -2 samples out of 12 positive, Gleason 6(3+3), both 30%
T1c
No treatment yet; following Ornish-style diet until a decision is made.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3733
   Posted 10/8/2011 2:12 PM (GMT -6)   
Ralph,
Good post. I have some questions about some of the studies in that it seems that they were all before the psa era. How were these men Dxed when psa was not available? The only way was through a DRE or that they were already symptomatic. This puts them all in a much higher risk catagory at DX then most men today and expectation is that they will fare far worse than the general population that is Dxed by psa today. I don't think you can connected this select high risk group with the general population.
As I said in a previous post I still can't get around the gross numbers that PC deaths account for 3% of all male deaths while autopsies show that men over 50 have a 50% chance of having PC and that number increases with age. There are millions of men walking around with PC that will never know they have it and it will never affect their lives. 16 out of 100 men will be DXed with PC and 40 to 60 will have PC and never know it. If 3 out of 100 die from it then the actual PC death rate for those who have it are 5% to 8%. and about 12%to 13% for those who are DXed with PC.
66 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, 4 weeks of urinary frequency and urgency; no side affects since then. 2 years of psa's all at 0.1.

golfnooch
Regular Member


Date Joined Sep 2011
Total Posts : 352
   Posted 10/8/2011 3:56 PM (GMT -6)   
what i would like to see is what are the mortality rates of fairly young men (40-50's) who are diagnosed but NOT treated...they just watchful wait and then die of something, whether it be the cancer or other causes. Also would be nice to see how quickly the disease progresses in those age groups as well.

ralfinaz
Veteran Member


Date Joined Jan 2011
Total Posts : 713
   Posted 10/8/2011 4:01 PM (GMT -6)   
JohnT,
Yes, those studies are mostly from the pre-PSA era. Why should that make a difference? If one is trying to learn what is the natural history of untreated PCa, what better history that that of the Scandinavian countries? Even if these men were diagnosed with more advanced disease, at one point before their diagnosis they had localized disease and as a continuum when left untreated resulted in a high mortality rate for many of them.

The “only” 3% death rate is driven and much related to dying of something else when the disease is diagnosed at an older age and by nature is slow-growing. As far as autopsy data you need to recognize that most of those men do not have clinical stage cases of prostate cancer. The majority has well-differentiated, low volume cancers. Very different than clinical disease.

The value of the studies cited should be evident. PCa can have a high mortality even when competing with other comorbidities. Age at diagnosis is an important data point because as demonstrated by these studies when untreated in a high percentage of cases it can kill. Also one has to recognize that progression of untreated PCa can and does affect quality of life. This has been ignored when they mention the harms of treatments versus doing nothing.

In the case of the pending USPSTF recommendations, if adopted as is and supported by the gatekeepers, there is no doubt in my mind that more men are going to die of PCa. This represents a step backward and an improper way to reduce overtreatment. If that is their objective…

RalphV
Phoenix, Arizona
DISCLAIMER: I am a prostate cancer survivor since 1992. The views or opinions expressed here are my own and are not endorsed nor supported by any agency or institution. Recommendations SHOULD NOT be construed as professional advice.
DX at age 58. RP; Orchiectomy; GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall; Stage T4; Last PSA July, 0'11: <0.1ng/ml

ralfinaz
Veteran Member


Date Joined Jan 2011
Total Posts : 713
   Posted 10/8/2011 4:08 PM (GMT -6)   
golfnooch said...
what i would like to see is what are the mortality rates of fairly young men (40-50's) who are diagnosed but NOT treated...they just watchful wait and then die of something, whether it be the cancer or other causes. Also would be nice to see how quickly the disease progresses in those age groups as well.


Golf,
The original post addressed your question with this:
"1. Prostate cancer mortality was 80% in men younger than 60 years, 63% in men 60-69 years old, 53% in men 70-79 years old and 49% in men older than 80 years.
Source.
Damber JE, Grönberg H .Mortality due to prostatic carcinoma in northern Sweden. : Urologe A. 1996 Nov;35(6):443-5"

Age at diagnosis is a significant factor as an increased risk of progression. Counting on avoiding PCa death by dying of something else is the wrong way of addressing the issue.

RalphV
Phoenix, Arizona
DISCLAIMER: I am a prostate cancer survivor since 1992. The views or opinions expressed here are my own and are not endorsed nor supported by any agency or institution. Recommendations SHOULD NOT be construed as professional advice.
DX at age 58. RP; Orchiectomy; GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall; Stage T4; Last PSA July, 0'11: <0.1ng/ml

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 10/8/2011 4:28 PM (GMT -6)   
ralfinaz,

There are both costs to society and benefits to society in every public health decision.
 
Many of the posts here are ineffective because they ignore the other perspective.  (Negotiation 101 lesson)

I would be interested in hearing your most balanced view on both sides, Ralph.

thanks in advance...

Post Edited (Casey59) : 10/8/2011 3:31:26 PM (GMT-6)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3733
   Posted 10/8/2011 5:16 PM (GMT -6)   
Ralph,
No one is questioning the need to treat clinically significant cancer. Klotz in his latest paper estimates an increased metastis rate of only 0.2 % for low grade G6 cancers in 20 years for those who remain untreated. I think it is very safe to say with all the evidence we have is that a large percentage of low risk cancers will never cause harm even given periods of 20 years. There are many other cancers, high volume G6 cancers and intermediate cancers that will surely continue to grow over the years and cause serious harm. When dealing with PC we often lump all PC together when if fact there is a very wide differentiation from not harmful to extremely harmful.
If we eliminate psa screening there is sure to be a rise in death rates as high volume G6 and G7 cancers that could be treated effectively will go undetected until it is too late.
JT
66 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, 4 weeks of urinary frequency and urgency; no side affects since then. 2 years of psa's all at 0.1.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24283
   Posted 10/8/2011 5:51 PM (GMT -6)   
excellent post, ralf, and i fully agree with your findings and conclusion.

it's time to rally the forces against those in opposition to PSA testing.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, 2/11 1.24, 4/11 3.81, 6/11 5.8
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24283
   Posted 10/8/2011 5:55 PM (GMT -6)   
p.s.

i dont think testing is being over done, which is resulting in a lot of early dx, which for the most part is a good thing.

why not put treatment for a PC dx on some kind of scale, to slow down the flow of alledged overtreatment.

for example, if someone has a dx of a single core, say 1-5% cancer, gleason 6, T1x, what we consider low grade, then simple not have insurance pay for immediate agressive treatment like surgery or radiation, and perhaps allow a careful year or two of AS before insurance would pay for treatment. If needed then, then insurance kicks in, if not, the patient either waits till there is sign of agression, or simply pays out of pocket if they insist on treatment. something along that line could work, and still serve the best interest of the patient.

david
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, 2/11 1.24, 4/11 3.81, 6/11 5.8
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 2354
   Posted 10/8/2011 5:59 PM (GMT -6)   
What about G-8, 9, 10 prostate cancer victims? Are we just going to be written off as hopeless cases, doomed to an ugly death regardless of screening or treatment?
Age 68.
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5, DRE "Abnormal"
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA <0.1 10/'11, <0.1

Aimzee
Veteran Member


Date Joined May 2010
Total Posts : 1183
   Posted 10/8/2011 6:00 PM (GMT -6)   
Thank you, Ralf.  I am not surprised.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3733
   Posted 10/8/2011 6:58 PM (GMT -6)   
Fairwind,
Didn't mean to leave you high risk guys out. We know we have to treat the higher grades, that's a given, and I don't think that many are treated as agressively as they should be. This post was about mortality of UNTREATED patients. We know that it is close to 100% for the higher grades, probably 40% to 50% for the intermediate guys, about 2-5% for the higher volume G6 guys and close to zero for the truely low risk guys. Without classifying patients into risk catagories studies like this and those that reflect treatment results are pretty worthless, because of the vast differences in outcomes for a G6 vs a G10. The risk catagory you are in, above all, has the most effect on your mortality outcome and your treatment outcome.
66 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, 4 weeks of urinary frequency and urgency; no side affects since then. 2 years of psa's all at 0.1.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7665
   Posted 10/8/2011 9:22 PM (GMT -6)   
JT Said:
"No one is questioning the need to treat clinically significant cancer. Klotz in his latest paper estimates an increased metastis rate of only 0.2 % for low grade G6 cancers in 20 years for those who remain untreated."

John, Klotz acknowledged that 0.2% of G6 patients will die by year 20 because they chose initial active surveillance. In Klotz's studies he showed about a 10% PCSM in G6 patients at year 20. These were treated patients that had no sign of metastatic disease at diagnosis and were qualified for AS.

Klotz also did a write up that I can't find right now that stated that 20% of G6 men would die by years 20 if they refused all therapy.

Ralph, that is a terrific write up. People don't recall the pre-PSA era because it's a generation behind us. The fact is that we have seen drastic drop in mortality that somehow gets excused by several defective studies. I think the biggest problem with todays screening studies is that they fail to mature. The screening study in Europe did a follow up at year 12 showing an increase in survival benefits however the critics continue to state the year 9 results and the US version of the screening trial.

Ugh!

Tony
Advanced Prostate Cancer at age 44 (I am 49 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
Da Vinci Surgery ~ 2/16/2007
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.
Undetectable PSA.

Blog: www.caringbridge.org/visit/tonycrispino

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 2354
   Posted 10/8/2011 10:53 PM (GMT -6)   
Statistics can be used to support virtually any agenda you are trying to promote...You just have to select a group of numbers that seem to support your cause..

Billions of dollars are on the table here...Give it a week or two and you will see a tsunami of reports and studies that support the position that PSA testing is VERY effective at saving lives...

davidg
Veteran Member


Date Joined Feb 2011
Total Posts : 4093
   Posted 10/9/2011 2:28 AM (GMT -6)   
Ralph that was a great post.

Purgatory - I can't agree with you. You are taking the choice away from the patient. I'm paying $1200 a month for health insurance and if told I have cancer, regardless of grade, I'll treat it as I bloody well choose. Besides, biopsy pathology reports are often upgraded by secondary labs and you go explain that to those lovely people that work at health insurance companies. I liked your other post about not bashing doctors because they're overwhelmingly good and know what they're doing. I'd extend that logic to this. If they believe in testing they should, and if they advise on surgery/radiation, as most of them seem to do, we should be given the option to listen and follow their expert advice.

The whole money argument is ludicrous to me. We spend more on completely idiotic military programs like the star wars program, or on wars designed to help us maintain global hegemony. Besides, like with health insurance in general, this is a moral issue before it is a financial one. The arguments that not enough people die to warrant testing border on vile at best in my opinion.
40 years old - Diagnosed at 40
Robotic Surgery Mount Sinai with Dr. Samadi Jan, 2011
complete urinary control and good erections with and without meds
Prostate was small, 34 grams.
Final Gleason score 7 (3+4)
Less than 5% of slides involved tumor
Tumor measured 5 mm in greatest dimension and was located in the right lobe near the apex.
Tumor was confined to prostate.
The apical, basal, pseudocapsular and soft tissue resection margins were free of tumor.
Seminal vesicles were free of tumor.
Right pelvic node - benign fibroadiopse tissue. no lymph node is identified.
Left pelvic node - one small lymph node, negative for tumor (0/1)

AJCC stage: pT2 NO MX

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2087
   Posted 10/9/2011 3:55 AM (GMT -6)   
A fundamental idea in medicine is all about where to put the boundaries between those who need to be treated and those who don't.
At some point doctors have decided where the boundary should be for PCa. That decision was based on the evidence that was available at that time. If new, or more importantly better, evidence is available now, then it seems reasonable to let the boundary be moved. After all, the new evidence could be saying that more testing of more men was needed on the basis of the evidence.

You can’t uninvent the PSA test, but at present I don’t think there is enough evidence to say that the PSA test doesn’t work. The testing and screening clearly need refining though, as does the information: there still seem to be people describing the PSA test as a test that detects prostate cancer. And frankly prostate biopsies need to be improved, they seem to be being done the same way they were 25 years ago. I say this as someone whose biopsy got the staging and Gleason wrong. It’s not much good trying to make decisions if you think you’re dealing with Gleason 6 stage 1, when it’s actually Gleason 7 stage 3. Spending money on colour imaging techniques and targeted biopsies might be a better way to spend money.

The dilemma seems to be purely about the cost. Not all Health provision is funded the same way, and this makes it difficult to call. I have little understanding of the system in the US having lived the first 25 years of my life in the UK with the NHS and having lived the second 25 years of my life in the Netherlands where we have had private insurance.

Someone has already posted a comment along the lines that they’ll believe it’s okay to alter screening methods when the politicians and doctors want to be screened less frequently, I’d agree with that way of looking at it, and I’d include the guys in charge of policy at the insurance companies too.

Alf
Age dx 48
04/09 PSA 8.6, DRE neg. Biop 2/12 pos. G=3+3
07/09 RALP at AVL Amsterdam
Cath out at 1wk Dry at night
PostOp G=3+4 Bladder neck & Left SVI -T3b. No PNI No vasc.inv. Clear margins
09/09 No pads
11/09 PSA 0.1
03/10 PSA 0.4 04/10 CT.
Summer/10 66Gy SRT
09/10 PSA<0.1
01/11 PSA<0.1
04/11 PSA<0.1
07/11 PSA<0.1
10/11 PSA<0.1
No real ED

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 2715
   Posted 10/9/2011 8:31 AM (GMT -6)   
davidg, your statement "I'm paying $1200 a month for health insurance and if told I have cancer, regardless of grade, I'll treat it as I bloody well choose. " is incredibly naive.  Unless you are totally paying for your treatment yourself, "someone" is making decisions about your options.  That someone may be an insurance company employeee or may be a government employee (or body), as in the case of socialized medicine.  But there is always a decision being made about what is reasonable and acceptable in light of both sound medicine and/or financial concerns.  That's just the way it is and to think otherwise is living in a fantasy world.
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1305643

davidg
Veteran Member


Date Joined Feb 2011
Total Posts : 4093
   Posted 10/9/2011 10:14 AM (GMT -6)   
my insurance didn't cover my surgeon. I ended up with him anyway cause I wouldn't have gone with anyone else. I truly believed he wa sthe best in my area. I squeezed everything I could out of my $1200 per month insurance and then negotiated the rest other ways. There is nothing naive about being your own advocate and giving yourself the power to make your own decisions.

Look at the uproar this idiotic/corrupt screening recommendation has generated. Imagine if they tried to enforce a rule whereby gleason 6 patients had to sit on AS for a few years. Good luck with that one.
40 years old - Diagnosed at 40
Robotic Surgery Mount Sinai with Dr. Samadi Jan, 2011
complete urinary control and good erections with and without meds
Prostate was small, 34 grams.
Final Gleason score 7 (3+4)
Less than 5% of slides involved tumor
Tumor measured 5 mm in greatest dimension and was located in the right lobe near the apex.
Tumor was confined to prostate.
The apical, basal, pseudocapsular and soft tissue resection margins were free of tumor.
Seminal vesicles were free of tumor.
Right pelvic node - benign fibroadiopse tissue. no lymph node is identified.
Left pelvic node - one small lymph node, negative for tumor (0/1)

AJCC stage: pT2 NO MX

ralfinaz
Veteran Member


Date Joined Jan 2011
Total Posts : 713
   Posted 10/9/2011 12:28 PM (GMT -6)   
Casey,
The USPSTF clearly makes these recommendations without considering costs to society. From the recommendation’s text:
“It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.”

That said, costs and benefits will always be considered given the finite amount of resources that can be committed to any given health issue by any society.

Since I believe that the current available evidence supports the benefit of PSA testing and early detection in saving lives, any cost analysis from me would by necessity tend to be more favorable but not unreasonable than one created by an entity that does not recognize the potential benefit of PSA testing.

That said, let me first mention that I have never supported mass screening for prostate cancer. It would be not only costly but presently ineffective with the current diagnostic tools and the lack of understanding that exists in the general population and even the medical profession in reference of what the PSA can and can not do. I do support awareness and education about the risks of PCa in an aging population. Developing a balanced informed consent form would go a long way in providing men with their options. Such forms exist now but in my opinion are so biased that any man in a normal state of mind, after reading them, would never accept to be tested.

The PSA test is a relatively inexpensive test that lacks specificity for prostate cancer but is highly specific for prostate gland problems such as infection, inflammation and prostate disease. A high level of PSA in blood is an indication that something is wrong in prostateland . All of these prostate problems could be symptom less as they evolve.
The holly grail of evidence-based medicine is the randomized clinical trial. Unfortunately these are few and far in-between as they relate to prostate cancer. Those that support or oppose their results often challenge their quality. In the 20 years I have been surviving PCa, this happens often enough to the point that we seem to always be waiting for trials to mature that would produce a definite answer. It seems to never come...

How to establish a fair cost/benefit analysis if none of the treatments have been proven (according to the USPSTF) to provide benefit, but are reported to induce harms? I see that a benefit of 20% reduction in mortality as reported by the ERSPC trial is said to be insignificant. This when the 20% reduction includes participants with intent to screen. That represents a good numberof men that had signed in to be screened, but never did attend, but were included as if they did. If those non-compliant and contamination men are taken out, the 20% death reduction becomes 31%. This is in a study in which participants were screened in multiple EU countries with different screening periods of more or less than 4 years.

I then look at part of the ERSPC trial done in Goteborg in which 20,000 men participated and were screened every 2 years. In this case the effect of screening in this population was a reduction of 41% in diagnosing advanced disease and a 44% reduction in PCa deaths. BTW, the USPSTF recommendation finds this part of the ERSPC trial as unusual because of the better results. In other words compliance is to be suspected. Also. there was no overall survival benefit for this trial. In other words, men who are diabetic, have vascular or heart disease when treated for prostate cancer and demonstrating a disease-specific survival after PCa treatment should be proven to live longer as if PCa treatment should improve their other conditions.and extend their existence.

Casey, at this point I find myself unable to develop an unbiased cost/benefit analysis for PCa because many other health issues do not have financial restrictions either. This recommendation to avoid PSA in asymptomatic men is not a solution for over diagnosis/over treatment. It represents a step backward and if approved as is it will have financial consequences in that those with health insurance will have to pay for the test as insurance companies will follow the USPSTF recommendations.
Ultimately the cost to society will be higher when faced to treat more men with advanced disease at diagnosis.

RalphV
Phoenix, Arizona
DISCLAIMER: I am a prostate cancer survivor since 1992. The views or opinions expressed here are my own and are not endorsed nor supported by any agency or institution. Recommendations SHOULD NOT be construed as professional advice.
DX at age 58. RP; Orchiectomy; GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall; Stage T4; Last PSA July, 0'11: <0.1ng/ml

ralfinaz
Veteran Member


Date Joined Jan 2011
Total Posts : 713
   Posted 10/9/2011 12:34 PM (GMT -6)   
JohnT,
I think our difference of opinion is that you believe that most of these G6 cancers do not metastasize and remain indolent for 20 as you mention. I do not think that Klotz has published any paper with a significant AS population with 20 years of followup.
I have read what I think is his latest review (April, 2011) and that reports an eight years median followup. That is hardly enough to declare no progression in a limited cohort of men. Understand that I support active surveillance as a method to stop what can be considered aggressive treatment in men. I do

Prostate cancer is a multi-step progressive disease with a wide-range, variable time span. In most men the disease progresses slowly, but in others progression is fast and unrelenting. In either case, the common factor is that disease progression is a continuum and, given enough time, it can evolve into a lethal disease by the process of dedifferentiation.

In the referenced studies with a high PCa mortality the disease progressed undetected from pre-cancerous to well differentiated lesions and on to different degrees of moderately differentiation and poor differentiation.
Age at diagnosis is a very important factor introducing the risk factor time.
I do not claim that every low-grade cancer will progress to kill the patient, but the risk is there when age at diagnosis is low. Men should be aware of this when educated about PCa.

RalphV
Phoenix, Arizona
DISCLAIMER: I am a prostate cancer survivor since 1992. The views or opinions expressed here are my own and are not endorsed nor supported by any agency or institution. Recommendations SHOULD NOT be construed as professional advice.
DX at age 58. RP; Orchiectomy; GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall; Stage T4; Last PSA July, 0'11: <0.1ng/ml

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7665
   Posted 10/9/2011 3:41 PM (GMT -6)   
Ralph,
I attended Klotz' latest presentation at PCRI and have the handout. The document clearly outlines from his own study:

Excerpt from the PCRI document:
The results with active surveillance are illustrated by a prospective study from Toronto, in which 450 patients were initially managed with active surveillance. From 1995 to 1999, patients with a favorable risk profile (Gleason score ≤6 and serum PSA ≤10 ng/mL) were offered active surveillance; less stringent criteria were used for patients over 70 years of age (serum PSA ≤15 ngl/mL or a Gleason score 3 + 4). From 2000 to 2005, enrollment was limited to the favorable risk category, regardless of age. Definitive treatment was recommended for a PSA doubling time of three years or less, histologic progression, or clinical progression.

The following findings were noted at a median follow-up of seven years:
• The 10-year overall survival for the entire cohort was 68 percent, and the 10-year prostate cancer specific survival was 97 percent.
• Definitive therapy was needed in 135 patients (30 percent), approximately one-half due to a short PSA doubling time and one-fourth due to histologic grade progression.
• Biochemical progression was observed in 50 percent of patients who underwent definitive therapy and in 13 percent of the entire cohort.
• Five patients died of prostate cancer, two of whom had refused definitive therapy.

--------

In his presentation Klotz acknowledges that G6 patients that NEVER get treated will have a prostate cancer specific mortality rate as high 2 in 10 or 20% twenty years after Dx. Additionally, Klotz acknowledged that 2 in 1000 patients will likely die a specific PCSM as a result of choosing AS as an initial protocol by year 20. In that same line he stated that this was statistical small when considering other causes of death.

The facts about AS are very important. Even the leading AS researchers agree there is a price but they disagree what that price is for selecting AS. None of the screening or AS studies have the maturity to tell us these facts. At least I haven't seen any and it amazes me that the USPSTF would make recommendations without the bigger picture. I think that Klotz' did a great job outlining the sobering truths:

#1 Gleason 6 disease has a higher mortality when the disease is left untreated over longer periods.
#2 Gleason 6 disease is is only suitable for AS when the patients are older or have other morbidity that will shorten life expectancy.
#3 Gleason 6 prostate cancer is still a potentially hazardous disease but it can be years to become a problem.

I think every patient that is considering AS must consider the guidelines very carefully before going on their own outside these guidelines for AS.

And age and life expectancy is hugely important.

Tony

Post Edited (TC-LasVegas) : 10/9/2011 3:22:51 PM (GMT-6)


ralfinaz
Veteran Member


Date Joined Jan 2011
Total Posts : 713
   Posted 10/9/2011 4:18 PM (GMT -6)   
Tony,
Thanks for the information about Klotz's presentation at the PCRI. Next month's presentation at the St. Joseph's Hospital group will be done by a member who attended the PCRI conference this year and the topic is Dr. Klotz's presentation. It is such an important topic for all of us and to promote for those that fit the protocols.

We have several members doing AS. They all go to either Duke Bahn or to Katsuto Shinohara for CDUS every year and are very well informed about the nuances of AS.
The sad note is that urologists have been slow in supporting AS as the best way to slow down over treatment. I understand the uncertainty of the current diagnosis, but for most men diagnosed with the proper number of biopsy cores and expertly confirmed G6 taking it slow and educating the patient should be the standard operating process. Will it get there? In time it will.

We must fight this USPSTF recommendation. I have read it twice and find many holes. This coming Tuesday we need to defend the current progress against this biased recommendation. To do that visit:
I encourage you all to post your comments Tuesday, 10/11/2011
at this website:

www.uspreventiveservicestaskforce.org/tfcomment.htm

RalphV
Phoenix, Arizona
DISCLAIMER: I am a prostate cancer survivor since 1992. The views or opinions expressed here are my own and are not endorsed nor supported by any agency or institution. Recommendations SHOULD NOT be construed as professional advice.
DX at age 58. RP; Orchiectomy; GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall; Stage T4; Last PSA July, 0'11: <0.1ng/ml

Aimzee
Veteran Member


Date Joined May 2010
Total Posts : 1183
   Posted 10/9/2011 10:37 PM (GMT -6)   
My husband picked up a copy of the local paper.  The headline:  HEALTHY MEN DON'T NEED TEST FOR PROSTATE CANCER, PANEL SAYS
 
Ron says to me, "I was healthy and I didn't have a previous elevated PSA score."  So, where is this going to leave millions of healthy men who actually have prostate cancer?  We will be protesting the USPSTF recommendation.

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2087
   Posted 10/10/2011 1:13 AM (GMT -6)   
Aimzee,
That headline defies logic if you ask me. Especially as I was a healthy man who had a Gleason 7 stage III inside him.
It's like saying that cars that haven't broken down don't need to go to the garage. They do however need regualr servicing.

Alf
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